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PowerPoint Presentation Rectal Examination Powered By Docstoc
					THE ROLE OF RADIOTHERAPY
   IN THE TREATMENT OF
GASTROINTESTINAL SYSTEM
          TUMORS


       Prof. Dr. Nuran ŞENEL BEŞE
Cerrahpaşa Tıp Fakültesi Radyasyon Onkolojisi
                 Anabilim Dalı
           GASTRIC CANCER
                 ETIOLOGY
•   Environmental factors
•   Inadequate sanitation facilities
•   Excessive dietary salt, smoked food, bad
    preservation of the food?
•   intestinal metaplasia
•   H. Pylori
•   Family history
•   Mostly seen in Aisan countries
•   Male predominance.
             PATHOLOGY
•   90-95 % Adeno ca
•   5 % Lymphoma
•   1-3 % Malign stromal sarcoma
•   0,3% Carcinoid
      PATTERNS OF SPREAD
•   Direct
•   Lymphatic pathway
•   Peritoneal
•   Hematogenous spread
    CLINICAL PRESANTATION
•   Fatigue
•   Weight loss
•   Nausea- vomiting
•   Dyspeptic symptoms
•   Disphagia
      PATIENT EVALUATION
•   Physical examination-Virchow’s nodule
•   Upper gastrointestinal radiographs
•   Endoscopy and biopsy
•   Abdominal CT
•   Chest x-ray
•   Bone scan in case of bone pain or
    tenderness in physical exam
    PROGNOSTIC FACTORS
• Local invasion
• The number of the involved lymph nodes
  and the regions of the positive lymph nodes
 TREATMENT OF GASTRIC CANCERS
• If the tumor is operable the only modality is
  surgery
• Surgery: Proximal-total
            Distal-subtotal
• To confirm resectability, provide pathological
  staging, re-establish gastrointestinal continuty.
• D1: perigastric lymph nodes
• D2: perigastric, celiac, left gastric, splenic, hepatic
  arteries
     SURVIVAL RESULTS OF
    GASTRIC CANCER AFTER
          SURGERY

• 5-year survival rate after the curative
  resection is 30-40 %
• Median survival is 6 months after the
  palliative resection
 ADJUVANT TREATMENT FOR
    GASTRIC CARCINOMA
• Surgical margin positive or close

• Serosal involvement

• Lymph node involvement
   ADJUVANT TREATMENT
• CT: 5FU and leukoverin
• Radiotherapy: gastric bed and perigastric, hepatic,
  splenic, celiac , paraaortic pancreatic-duodenal
  lymph nodes are irradiated. Treatment fields are
  chosen according to the localization of the tumor,
  lymph node dissection and the location of
  involved lymph nodes.
• Kidneys, spinal axes, small intestines are dose
  limiting organs
    FACTORS TO BE CONSIDERED
       DURING IRRADIATION
•   Toxicity is high
•   Supplementation, prevention of weight loss
•   Weekly complete blood cell count
•   Iron and B12 supplementation
  CANCER OF THE RECTUM
• Anal verge 14 cm
• Retro and infra-peritoneal
• Lymphatic spread: internal-external-
  common iliac
     PATHOLOGY OF RECTUM

• 90 % Adenocarcinoma
• Others:
     Carcinoid
     Leiomyosarcom
     Lymphoma
     Squamous cell ca
      ETIOLOGY OF RECTAL
          CARCINOMA
• Genetic
• Chronic ulcerative colitis
• Familial adenomatous polyps
• Factors related with diet (low intake of fiber
  and selenium)?
• Male=Female
   CLINICAL MANIFESTATIONS AND
             DIAGNOSE
• Bleeding
• Change in the bowel frequency
• Physical examination: Virchow’s nodule
                   Rectal examination
• Blood cell count
• Radiography: Barium radiography
                Abdominopelvic CAT
                Chest x-ray
• Colonoscopy and biopsy
      PATTERNS OF SPREAD

• Direct invasion: sacrum, vagina, bladder
• Lymphatic pathway
• Hematogenous spread
STAGING OF RECTAL CARCINOMA
•   TNM
•   AJCC/UICC
•   DUKES
•   ASTER COLLER
•   MODIFIED ASTER COLLER
TREATMENT OF RECTAL
    CARCINOMA
• Surgery; primary treatment modality
• MAC A – B2:No need for adjuvant
  treatment
• TNM T1-2 N0 M0
   %< 10 local recurrences
  %> 80 survival
       SURGERY OF RECTAL
          CARCINOMA
*Sphincter conserving surgery;
   - Anterior Resection (Mayo - Dixon op)
   - Low Anterior Resection
   - Total Mesorectal Excision ( TME)
* Other;
   - Abdominoperineal Resection ( Miles op)
 POSTOPERATIVE TREATMENT OF
   RECTAL ADENOCARCINOMA
• MAC Stage B3, C1, C2 and C3
• TNM StageT3-4 N0 M0 and T1-4 N1-2 M0
• Patients candidates for adjuvant treatment (post-op
  RT):
             SM (+) or close
             Lymph node involvement
             Serosal involvement
• Adjuvant CT + RT combination
• 2 cycles CT/ concomitant CT+RT/ 2 cycles CT
       PRE-OP RADIOTHERAPY FOR
          RECTAL CARCINOMA
• ADVANTAGES;                     • DISADVANTAGES;
 -Tissue oxygenation               -Delay for the excision of
 -Sterilization of viable cells     tumor
 -Unresectable tm =>               -No real pathologic staging
  operable                         -Increased surgical
                                    complication
 -APR => sphincter preserving
  surgery                          -Delay of wound healing
 -Less morbidity of small          -Over treating of the patients
  intestines                        with early stage
      PRE-OP RADIOTHERAPY FOR
          RECTAL CARCINOMA
      currently recommended treatment
                   modality
• Short Course Pre-op RT; (Sweden study)
   5Gy/fr total 25Gy/ 5fr KT Ø
   local control and survival is better compared with
  surgery
• Long Course Pre-op RT; (German study)
  50.4Gy/30fr
  5FU 1000mg/m2/d( CI 1. and 5. weeks of RT)
  Increased local control, decreased toxicity compared
  with post-op RT
         RADIOTHERAPY FOR
        INOPERABLE RECTAL
            CARCINOMA
• Concomitant CT + RT
• 45Gy (1.8Gy/ fr )
• Radiology and rectal examination; operable =>
  surgery
• Inoperable after 45Gy => 54- 60Gy
SIDE EFFECTS OF TREATMENT
• EARLY SIDE EFFECTS;
  Skin reactions
  Diarrhea
  Bladder complication
  Decrease in white blood cell count
• LATE EFFECTS;
  Fibrosis of the soft tissue
   Sub-ileus
   Rectit
   Proctit
       CANCER OF THE ANAL
          CARCINOMA
          EPIDEMIOLOGY- ETIOLOGY
• Female/Male=1.7 but changing
• Incidence is increasing. Male under 35 years old
• HPV 16
  HSV 2
  Related with AIDS
  Smoking
  Genital warts
  Homosexuality
ANAL CARCINOMA: PATTERNS
OF SPREAD AND PATHOLOGY
• Pathology:
     Squamous cell cancer 70%
     Adeno ca 30 %
• Patterns of spread:
     Direct invasion
     Pelvic lymphatic 30%-inguinal 20%
  ANAL CARCINOMA: CLINICAL
 PRESANTATION AND DIAGNOSE
• Clinical presentation: bleeding
                         anal mass
                         discharge
• Physical exam: inguinal gang.
• Diagnose: biopsy
• Abdominopelvic CAT
• Blood cell count
      TREATMENT OF ANAL
         CARCINOMA
• Both in early stage and advanced disease
  CT+RT
  CT: 5-FU-mitomisin + 45Gy RT (concomitant)
      6 weeks CR: 15Gy boost
              PR: 20Gy boost
  Colostomy free survival for 3-year: 50 %
• Local recurrence: APR

				
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posted:9/10/2010
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Description: PowerPoint Presentation Rectal Examination